Laserfiche WebLink
SII 3jr SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> <. 1 <br /> FOF OFFiCB USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> t `g - Telephone. (209) 466-6781 - {� ' ' _, } <br /> PLICATION FOR WELL.CONSTRUCTION OR PUMP PERM Permit No,�7-/o 7� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 <br /> d (Complete In Triplicate) <br /> Application is hereby made toithe San Joaquin Local Health District for a permit to construct ' <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and"the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 111501 East Highway 120 �� CENSUS TRACT <br /> Owner's Name MarialKontinakis r ; Phone 982-4105 <br /> Address 175761 Louise Avenue Escalon California City Escalon <br /> R <br /> Contractor's Name .J_Ax� Porter License # 7Phonek-5E-.2W,6,# <br /> t .. - <br /> i <br /> VPE OF WORK (Check) : NEW WELL /37 DEEPEN /_7 RECONDITION /7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR J / PUMP REPLACEMENT /_ <br /> + Other <br /> -3iS-T-ANCE-TO-NEAREST:* SEPTIC -TANK SEWER LINES` PIT PRIVY 4 <br /> SEWAGE <br /> DISPOSAL FIELD CE SPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL/a-<PTJBLIC DOMESTIC WELL __ \ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS fn. <br /> Industrial Cable 'fool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing_ -------�--�- <br /> X Irrigation .,Grave-l--Rack Grave•1--Pack9- +-` DaptYt"b 'Grouf`Seal <br /> --" Cath`odic Protection Rotary Type of Grout <br /> Disposal tither Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ` <br /> i <br /> PUMP REPLACEMENT.:. - /7/- a'te 'Work Done <br /> RUMP -REPAIR: / / State Work Done N <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> C <br /> Q Describe Material and Procedure <br /> � I hereby agree to comply with�all laws and regulations of the San Joaquin Local Health District <br /> land the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the bes y knowledge and belief. I WILL CALL FOR A GROUT INSP CTION <br /> PRIOR TO GROUTING AND A FIN NS CT - <br /> SIGNED < TITLE <br /> (DRAW=T PLAN ON REVERSE SID �.t <br /> FOR DEPARTMENT USE ONLY Ur✓ <br /> PHASE I !7,x-7 <br /> 'APPLICATION ACCEPTPD-BY-- ---__0 I D TE ( /f /i <br /> ADDITIONAL'" COMMENTS�{ An <br /> fGw 315 <br /> PHAS ° G OUT I _.ECT ,'PHASE JI /FINAL,kNSP C <br /> INSPECTION BY DATE 6 -7 INSPECTION BY �/f �, DAT. z y. 77 <br /> 1 <br /> /77 <br /> E H 1426 Rev. 1-7 � ' � % <br />